15 мая 2023

Авторы: Садыкходжаева Дилорам
Субъект РФ: Ташкент

The Ministry of Health developed a national policy on quality improvement in Uzbekistan. In 2004, the Centre for Evidence-Based Medicine was set up at the Tashkent Institute of Postgraduate Medical Education [6].  National standards for diagnosis and treatment and clinical protocols for primary health care were developed by specialists from the Centre for Evidence-Based Medicine. These clinical guidelines are valuable and reliable resources both for the GPs’ training and their daily work.

To understand the power of training and how well its meeting the trainees' needs, the process of teaching must be measured and evaluated. Traditional continuing medical education programs that offer passive learning have been shown to be poorly effective at changing doctors' clinical behaviour [7]. In Uzbekistan, no study thus far has examined the association between the teaching of EBM principles and doctors' clinical behaviour following evidence based guidelines.  EBM courses conducted at the largest GPs’ group are designed to facilitate a change in doctors' attitudes, knowledge and clinical behaviour.

Aims and objectives

The aim of this study was to evaluate the efficacy of 5-day postgraduate EBM courses for GPs working in SVPs (rural health clinics), to assess the progress towards achieving training programme objectives, to analyse problems and select the most valid interventions from a set of options, in order to improve skills in the management of childhood diseases at  primary health clinics following the implemented evidence based guidelines.

Materials and methods

All courses were conducted in the department of Public Health and Healthcare Management at Tashkent Institute of Postgraduate Medical Education. EBM programmes and training materials were developed, and 5-day seminars were held. 728 general practitioners from 14 regions were trained every month between September 2021 and January 2022.          

The study evaluated the acquired competency pre test (before training) and post test (after training), and measured the primary outcomes of knowledge, appraisal skills, and changing GP attitude with attention to following the clinical practice guidelines. Child health is one of the core conditions covered by the Uzbek primary care package. The list of indicators, based on the guidelines, includes the most essential and prioritized ones, which demonstrate the skills of GPs to assess sick children, their ability to determine treatment and to prescribe medications. In addition, introduction of principles of EBM in the framework of implementing guidelines allows to explain its content and increase substantially the participants' knowledge in child diseases.

Results

All outcomes were measured before and after the seminars, and evaluation done after 15 months. Efficacy evaluated by using questionnaires to assess knowledge, skills, attitudes, and the intention to apply EBM and to follow recommended guidelines.

All posttest participants scored on average more than 80%, which is encouraging and shows the effectiveness of the training. There were substantial changes in the level of knowledge acquisition - up to 90%; the effect of the training on changing  attitudes to using EBM principles and recommended guidelines' - up to 68%.

We evaluated the effect of the seminar on GPs’ clinical performance after training. Interactive seminars are more effective for changing behaviours and essential for ensuring that they maintain and learn new skills and competencies. The most notable improvement among participants was in infection prevention and diarrhoea management in children under 5, as shown by four quality of care outcome measures.

Analysis of outcomes data showed that many GPs applied the skills obtained in the practical work, but did not always implement them according to the guideline strategy. After taking the EBM course, some of participants believed they were better able to interpret published valid clinical evidence but not better able to apply those results to the care of individual patients. The challenges are the lack of appropriate conditions, the effect of time and financial constraints, lack of equipment and the absence of an effective computer system. A passive attitude, and lack of motivation and willingness means that they do not introduce the new approaches in their daily practice.

Limits

EBM teaching has a positive impact on health providers’ care. Questionnaires have been shown to be useful in assessing the knowledge and skills of participants. Barriers to implementation of EBM  into practice are the lack of resourses to provide access to reliable sources of information, such as websites; outdated methodology in medical education; lack of skills to perform searches for scientific data, to evaluate their validity and to transform scientific data into practical solutions, which is necessary for health workers in their daily activities.

In addition, we did not assess how EBM teaching improves performance in the clinical setting. There is a need for further follow-up assessment and monitoring of trained groups of GPs to assess the effectiveness of educational intervention in reducing child morbidity and improving outcomes. Future larger-scale interventions must be incorporated into the routines of the organisation, thus minimising barriers towards EBM implementation.

Conclusion

In summary, we suggest these seminars can significantly improve EBM knowledge and increase the use of guidelines and evidence based resources by GPs. Future studies are needed to clarify the impact of EBM teaching in improving clinical performance or patient outcomes. The experience showed that simply training health workers does not guarantee application of the skills gained in practical work. However, the quality of the services can be improved even without considerable financial resources following evidence based guidelines.